Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

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Media Decoder Blog: CBS Reports Record Operating Income for 4th Quarter

The CBS Corporation set records in the fourth quarter for operating income and adjusted operating income, the company said Thursday, but the results were short of some analysts’ expectations, causing its share price to fall slightly in after-hours trading.

The adjusted net earnings of $414 million produced earnings per share of 64 cents, also a new quarterly record for CBS, though some analysts had forecast a price as high as 69 cents.

CBS, which reported full-year results for 2012 as well as for the quarter ending Dec. 31, also announced an additional stock buyback of $1 billion. That brings the total amount of stock CBS has committed to repurchasing for the current year to $2.2 billion.

Over all, CBS demonstrated improved results in most financial categories and divisions. Revenues for the quarter rose to $3.7 billion, up 2 percent from $3.61 billion for the comparable quarter in 2011.

The company reported net income of $393 million, or 60 cents a share, up 6.2 percent from $370 million, or 55 cents a share, in the fourth quarter of 2011.

CBS cited increases in advertising revenue in the quarter, partly driven by political commercials in an election year. The CBS broadcast network continues to be the most watched in television and will likely beat all its competitors in the significant ratings categories for the current season.

The company also saw increases from subscription fees, driven by improvement in its cable networks. Showtime, the pay-cable channel owned by CBS, has experienced growth in subscriptions, thanks in part to its award-winning drama “Homeland.” CBS has pressed for years for increased compensation from cable systems for the rights to carry CBS broadcast stations, and Thursday the company reported that retransmission fees were also up for the quarter, part of 9 percent growth overall in affiliate and subscription fees.

Adjusted operating income before depreciation and amortization increased 6 percent, to $866 million from $814 million the year before. Operating income increased 12 percent to $726 million, up from $647 million.

For the full year CBS also produced some encouraging results. The company reported revenues of $14.09 billion, up 3 percent from $13.64 billion in 2011. Adjusted income increased to $3.49 billion from $3.16 billion. Operating income of $2.98 billion was up from $2.62 billion in 2011. All represented new highs for CBS.

One more troubling area was publishing. CBS’s Simon & Schuster unit experienced a decrease in revenues, to $215 million from $229 million in 2011. CBS attributed the drop to decreasing print book sales that could not be offset by increasing e-book sales.

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IHT Special: Tunisia Sinks Back Into Turmoil

TUNIS — Following the murder of a leading opposition politician, Tunisians are asking whether the Arab Spring, which began in their country, has accomplished much of anything. They are disenchanted with the fits and starts of the transition from dictatorship to something else.

“Nobody likes the situation and this government has to change,” said Rabbeh Souly, 28, who sped up her steps on the pavement in central Tunis after witnessing a mugging. “They need to fix the things that concern people like unemployment and poverty. Before, at least things were calm and safe. I regret Ben Ali is gone.”

She was speaking of the longtime dictator Zine el-Abidine Ben Ali, who was ousted two years ago. His departure ushered in a transition coalition government led by the Islamists.

Now Tunisia is at a crossroads. Violence has been escalating for months and the general political atmosphere has been deteriorating. This was underscored by the murder of leftist opposition leader Chokri Belaid, who was shot in front of his house by unidentified assailants last week. The killing came as a shock to both ordinary people and to the political establishment.

Thousands of Tunisians took to the streets after Mr. Belaid’s death, vowing revenge in scenes reminiscent of the protests in 2011.

“With our souls, with our blood, we will avenge you Belaid,” they chanted in the rain on a march to the cemetery.

In the halls of government buildings, another drama played out. The prime minister, Hamadi Jebali, called for the government to resign in favor of a technocratic leadership. But his own Ennahda party disavowed his call.

Ennahda, a moderate Islamist party, has been the strongest political group following the departure of Mr. Ben Ali, winning elections in October 2011 handily because it was viewed as very different from the strongman and his cronies.

But after the assassination of Mr. Belaid, the party has been forced into retreat, while the secular leftist opposition has been given new momentum and unity.

“The country entered a new political cycle: It was in a difficult political transition that was marked by phases of instability and now we are seeing a radicalization of political actors,” said Vincent Geisser, a researcher at the French Institute for the Near East who is based in Beirut, speaking of Islamists and secularists. “There is a serious need for dialogue before there is another assassination.”

The challenges are real: The country is dealing with a weak economy that contracted by 1.8 percent in 2011 and grew by an estimated 2.7 percent last year — not enough to reduce unemployment, which is running at about 17 percent, up from 13 percent at the end of the old regime.

Political instability is also frightening away tourists. Tourism was a key source of jobs and income in the past.

The turmoil is hurting just about everyone.

“Political parties are fighting and the Tunisian people are paying for it,” said Mohamed Ben Amor, sweeping in front of a bodega after a protest on Avenue Bourguiba. “The country is deeply affected by the problems that are happening, so business has been really bad.”

Tunisians lay the blame at Ennahda’s door for failing to address the roots of popular discontent and maintain order in the country, while creating an atmosphere in which religious radicals get away with making violent threats against the secular opposition.

Violence has been escalating in Tunisia over the past two years. Extremists have attacked tombs they consider sacrilegious and a TV station they believe has violated their conservative religious beliefs. In Sidi Bouzid, a city in central Tunisia, the extremist Salafis vandalized a bar in September.

Rachid Ghannouchi, a founder and leader of the Islamist party, who was recently called an “assassin” by demonstrators, strongly denies that the party has promoted violence.

“Ennahda never resorted to violence, it’s not part of our ideology,” he said during an interview in one of the party’s offices in Tunis.

“We are in power, but we feel like we are in the opposition. We don’t have any political party that stands by our party,” he added.

Even so, many blame Ennahda for the political turmoil and worry about a takeover by the military.

“Most Tunisians are held hostage by this kind of radicalization of the political spectrum,” Mr. Geisser said. “This stubbornness to not listen to each other could lead to a takeover by the security apparatus.”

Fares Mabrouk, a co-founder of the Arabic Policy Institute, a research concern in Tunis, believes that the shorter the transition period, the more chances the country has to get back to a more stable political climate. The current government is only supposed to remain until a constitution is in place and new elections are held.

“There is today an opportunity to create a historical compromise that will be unique to Tunisia, and unique in the Arab world,” he said. “The murder of Chokri Belaid and the unification of the left will balance the forces.”

The constitution is not finished and there is no date set yet for elections. This fight over political legitimacy is hurting the country.

“We have two equal forces and it can lead to civil war,” Mr. Mabrouk said. “The first one has electoral legitimacy and the other has now a martyr that is giving them legitimacy. With the political future so unclear, no Tunisian or foreign businesses will invest.”

But for many Tunisians, the murder of Mr. Belaid was a call to even greater political activism.

“I am in a state of shock, but actually there are thousands of Chokri Belaids,” said Mounji Ayari, 43, who wept as he held a sign with a picture of Mr. Belaid that read “martyr” at the funeral. “He is someone who taught us rebellion. He may be dead but he will forever stay with us and we will make sure his ideals live on.”

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Barry Bonds seeks dismissal of felony conviction

SAN FRANCISCO (AP) — A lawyer for Barry Bonds urged a federal appeals court on Wednesday to toss out the slugger's obstruction of justice conviction, saying a rambling answer he gave while testifying before a grand jury was not a crime.

Appellate specialist Dennis Riordan argued that Bonds was not formally or specifically charged with the felony that he was convicted of committing. A federal jury in April 2011 found baseball's all-time home runs leader guilty of obstruction for saying he was a "celebrity child" when asked about injecting steroids.

Prosecutors asked Bonds during his December 2003 grand jury appearance whether Greg Anderson, his personal trainer, ever gave him "anything that required a syringe to inject yourself with?"

Bonds referred to his father, former major leaguer Bobby Bonds, when he responded "that's what keeps our friendship. You know, I am sorry, but that — you know, that — I was a celebrity child, not just in baseball by my own instincts. I became a celebrity child with a famous father. I just don't get into other people's business because of my father's situation, you see ..."

That particular exchange wasn't included in the indictment originally released in November 2007. The omission is "the dagger in the heart of this conviction," Riordan argued.

Further, Riordan said that Bonds ultimately answered the question when put to him again and denied receiving any substance to inject.

Judge Michael Daly Hawkins wondered aloud if Bonds' direct denial undercut the government's argument that Bonds intentionally misled the grand jury.

Assistant U.S. Attorney Merry Jean Chan countered that the denial was a lie because Bonds' former personal assistant, Cathy Hoskins, testified that she witnessed Anderson inject Bonds. Chan said Bonds' denial and his other rambling answers to the same question throughout his grand jury appearance added up to obstruction.

"He answered the question falsely each time," she said.

Bonds and his legal team are asking a three-judge panel of the U.S. 9th Circuit Court of Appeals to dismiss the lone felony conviction stemming from Bonds' 2½ hours of testimony in December 2003 before a grand jury investigating performance enhancing drug use and sales among elite athletes. Bonds, who was rejected by voters last month in his first year of eligibility for the Hall of Fame, wasn't required to attend Wednesday's highly technical hearing, though Riordan said his client expressed a desired to watch the proceedings in person.

Riordan said outside court that he advised Bonds to watch from afar rather than personally attending the 35-minute session San Francisco. A local television station was given permission to show the hearing live and streamed at least a couple of segments on the Internet.

"His presence would have been a distraction," Riordan said.

Legal experts who have followed the case closely since his grand jury appearance in December 2003 are divided over Bonds' chances before Daly Hawkins and Judges Mary Schroeder and Mary Murguia, each of whom was appointed by a different Democrat president and all of whom are based in Phoenix, home of San Francisco's division rival Diamondbacks and about a 20-minute drive from the Giants' Scottsdale spring training facility.

One set of analysts argue that appellate courts are reluctant to overturn jury verdicts absent an overwhelmingly obvious mistake. They say that U.S. District Judge Susan Illston, who ran the trial, is a respected jurist who has few of her cases overturned.

"There is a definite overriding respect of a jury's verdict," said Howard Wasserman, a Florida International University law professor. "Typically, it's pretty hard to get a jury's verdict reversed."

On the other hand, there are those lawyers who argue that Bonds stands a good chance to clear his name.

"The government's biggest hurdle is that testimony obstruction cases are usually based on blatant, undeniable lies to questions at the heart of an investigation," said William Keane, a San Francisco criminal defense attorney. "Here the prosecution limps in with only a single rambling, unresponsive, unimportant answer that is literally true."

Regardless of the outcome, University of New Hampshire law professor Michael McCann contends that the case was ultimately a loss of the U.S. Department of Justice. In a case that put a superstar athlete at the defendant's table, the jury deadlocked on three charges of making false statements

"The main thrust of the government's original case was that he lied when he denied taking steroids," said McCann, who also edits the popular Sports Law Blog. "That's not what he was convicted of. Obstruction was not the main charge."

If Bonds' conviction is upheld, he will have to serve 30 days house arrest.

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Phys Ed: Getting the Right Dose of Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

Fitness Tracker

Marathon, half-marathon, 10k and 5K training plans to get you race ready.

A common concern about exercise is that if you don’t do it almost every day, you won’t achieve much health benefit. But a commendable new study suggests otherwise, showing that a fairly leisurely approach to scheduling workouts may actually be more beneficial than working out almost daily.

For the new study, published this month in Exercise & Science in Sports & Medicine, researchers at the University of Alabama at Birmingham gathered 72 older, sedentary women and randomly assigned them to one of three exercise groups.

One group began lifting weights once a week and performing an endurance-style workout, like jogging or bike riding, on another day.

Another group lifted weights twice a week and jogged or rode an exercise bike twice a week.

The final group, as you may have guessed, completed three weight-lifting and three endurance sessions, or six weekly workouts.

The exercise, which was supervised by researchers, was easy at first and meant to elicit changes in both muscles and endurance. Over the course of four months, the intensity and duration gradually increased, until the women were jogging moderately for 40 minutes and lifting weights for about the same amount of time.

The researchers were hoping to find out which number of weekly workouts would be, Goldilocks-like, just right for increasing the women’s fitness and overall weekly energy expenditure.

Some previous studies had suggested that working out only once or twice a week produced few gains in fitness, while exercising vigorously almost every day sometimes led people to become less physically active, over all, than those formally exercising less. Researchers theorized that the more grueling workout schedule caused the central nervous system to respond as if people were overdoing things, sending out physiological signals that, in an unconscious internal reaction, prompted them to feel tired or lethargic and stop moving so much.

To determine if either of these possibilities held true among their volunteers, the researchers in the current study tracked the women’s blood levels of cytokines, a substance related to stress that is thought to be one of the signals the nervous system uses to determine if someone is overdoing things physically. They also measured the women’s changing aerobic capacities, muscle strength, body fat, moods and, using sophisticated calorimetry techniques, energy expenditure over the course of each week.

By the end of the four-month experiment, all of the women had gained endurance and strength and shed body fat, although weight loss was not the point of the study. The scientists had not asked the women to change their eating habits.

There were, remarkably, almost no differences in fitness gains among the groups. The women working out twice a week had become as powerful and aerobically fit as those who had worked out six times a week. There were no discernible differences in cytokine levels among the groups, either.

However, the women exercising four times per week were now expending far more energy, over all, than the women in either of the other two groups. They were burning about 225 additional calories each day, beyond what they expended while exercising, compared to their calorie burning at the start of the experiment.

The twice-a-week exercisers also were using more energy each day than they had been at first, burning almost 100 calories more daily, in addition to the calories used during workouts.

But the women who had been assigned to exercise six times per week were now expending considerably less daily energy than they had been at the experiment’s start, the equivalent of almost 200 fewer calories each day, even though they were exercising so assiduously.

“We think that the women in the twice-a-week and four-times-a-week groups felt more energized and physically capable” after several months of training than they had at the start of the study, says Gary Hunter, a U.A.B. professor who led the experiment. Based on conversations with the women, he says he thinks they began opting for stairs over escalators and walking for pleasure.

The women working out six times a week, though, reacted very differently. “They complained to us that working out six times a week took too much time,” Dr. Hunter says. They did not report feeling fatigued or physically droopy. Their bodies were not producing excessive levels of cytokines, sending invisible messages to the body to slow down.

Rather, they felt pressed for time and reacted, it seems, by making choices like driving instead of walking and impatiently avoiding the stairs.

Despite the cautionary note, those who insist on working out six times per week need not feel discouraged. As long as you consciously monitor your activity level, the findings suggest, you won’t necessarily and unconsciously wind up moving less over all.

But the more fundamental finding of this study, Dr. Hunter says, is that “less may be more,” a message that most likely resonates with far more of us. The women exercising four times a week “had the greatest overall increase in energy expenditure,” he says. But those working out only twice a week “weren’t far behind.”

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Stock Indexes End Mixed

The stock market lacked direction on Wednesday, as a slump in McDonald’s stock helped pull the Dow Jones industrial average below 14,000. Other major market indexes were marginally higher.

McDonald’s was among the biggest decliners in the Dow, losing $1.10, to $94, as investors worried that Americans were spending less on eating out after a rise in Social Security taxes at the beginning of the year. The government reported early Wednesday that spending by Americans barely grew last month.

Other fast-food companies also fell. Buffalo Wild Wings stock plunged $4.52, to $76.55, after its earnings fell short of analysts’ expectations. Burger King and Wendy’s also fell.

“Consumer spending is coming under pressure,” said Bryan Elliott, an analyst at Raymond James. “It’s the easiest way to save money; stay at home and cook.”

The Dow Jones industrial average fell 35.79 points, or 0.26 percent, to 13,982.91. The Dow is still up 6.71 percent so far this year and is just 182 points below the record close of 14,164 set on Oct. 9, 2007.

The Standard & Poor’s 500-stock index edged up 0.90 point, or 0.06 percent, to 1,520.33. The index climbed as high as 1,524.69 during the day, the highest since November 2007. It is up 6.6 percent so far this year.

The Nasdaq composite index rose 10.38 points, or 0.33 percent, to 3,196.88.

Investors sent General Electric and Comcast higher after G.E. agreed Tuesday to sell its stake in NBCUniversal to Comcast for $16.7 billion. G.E. said it would use up to $10 billion of the money to buy back its own stock. Shares of G.E. rose 81 cents, to $23.39. Comcast advanced $1.16, to $40.13.

Trading has been relatively quiet in recent days following a strong opening to the year.

“We’re cautiously optimistic on stocks,” said Colleen Supran, principal at Bingham, Osborn & Scarborough. “There is some indication that we could be continuing on this slow growth trajectory.”

Ms. Supran said investors should still be prepared for volatility in the stock market and not assume that the gains from January and so far in February will set the pattern for the rest of the year.

Strengthening the economy and creating jobs were major topics in President Obama’s State of the Union address Tuesday. Although the economy is healthier than it was four years ago, growth remains slow and unemployment high.

The government reported that spending at retail businesses and restaurants slowed last month after higher taxes cut paychecks. Retail sales growth slowed to 0.1 percent in January, from a 0.5 percent increase in December.

Among the stocks on the move, Groupon rose 28 cents, to $5.57, after the brokerage firm Sterne, Agee & Leach, raised its rating on the company to buy from neutral, citing the long-term potential for Groupon’s changing business model. The online deals company has lost almost three-quarters of its value since going public in November 2011 at $20 as revenue growth slowed.

Dean Foods, a milk producer, fell $1.69, or 9.19 percent, to $16.70, after its profit forecast fell short of Wall Street expectations.

As stocks have advanced this year, bond prices have slumped and interest rates have risen. On Wednesday, the price of the 10-year Treasury note fell 13/32, to 96 15/32, while its yield rose to 2.03 percent, from 1.98 percent late Tuesday.

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The Lede: Latest Updates on the Pope’s Resignation

The Lede is providing updates on Pope Benedict XVI’s announcement on Monday that he intends to resign on Feb. 28, less than eight years after he took office, the first pope to do so in six centuries. (Turn off auto-refresh to watch videos.)

4:17 P.M. |Subtitled Video of Pope’s Resignation Statement

The Telegraph has added English subtitles to video of the pope’s resignation statement, made in Latin to cardinals at the Vatican on Monday.

Video of Pope Benedict XVI announcing his intention to resign.

Later in the day, the photojournalist Alessandro Di Meo captured a striking image of St. Peter’s Basilica during a thunderstorm that drenched the Vatican.

Lightening strikes St Peter’s on day #Pope Benedict announces resignation from Vatican (pic ANSA) http://t.co/09KGgZNl
— Jon Williams (@WilliamsJon) 11 Feb 13

— Robert Mackey

3:24 P.M. |The Vatican’s Electoral College

As the Vatican newspaper L’Osservatore Romano reports, the Catholic News Service has published a complete list of the cardinals, “from oldest to youngest, eligible to vote for a pope in a conclave.” The oldest, Cardinal Walter Kasper, will be 80 years old on March 5, so “depending on the date of the conclave, he might be over 80, and thus too old to vote.”

Full list of potential cardinal-electors for a papal conclave: http://t.co/qzl9NFTY
— L’Osservatore Romano (@LOsservatoreUSA) 11 Feb 13

The youngest elector, 53-year-old Cardinal Baselios Cleemis Thottunkal of the Syro-Malankara Catholic Church from India, was appointed less than three months ago by Pope Benedict XVI.

A video report on Cardinal Baselios Cleemis Thottunkal, major archbishop of the Syro-Malankara Catholic Church.

— Robert Mackey

2:11 P.M. |Pope Decided to Step Down ‘Months Ago’

As our colleague Rachel Donadio reports, the editor of the Vatican newspaper L’Osservatore Romano said that the pope made his decision to step down nearly a year ago after a trip to Mexico and Cuba. The pope made up his mind “after his trip to Mexico and Cuba, and having repeatedly examined his conscience before God, due to his advancing age,” the editor, Giovanni Maria Vian, said.

Vatican newspaper says Benedict made his decision to resign “many months ago” after his trip to Mexico & Cuba March 2012. He was tired then.
— Rachel Donadio — NYT (@RachelDonadio) 11 Feb 13

Vatican newspaper frontpage: “Benedict XVI leaves the pontificate” http://t.co/PS3bwOR7
— Catholic News Svc (@CatholicNewsSvc) 11 Feb 13

The German newspaper Die Welt reports that the pope’s brother, Father Georg Ratzinger, who is also a Catholic priest, said that he had known of the impending announcement for many months.

A German television interview with the pope’s older brother, Father Georg Ratzinger, on Monday.

As the Catholic News Service reports, the pope had previously hinted that resignation was a possibility for him:

The German author and journalist Peter Seewald asked Pope Benedict in the summer of 2010 whether he was considering resigning then, a time when new reports of clerical sexual abuse were being published in several European countries.

“When the danger is great, one must not run away. For that reason, now is certainly not the time to resign,” he told Seewald, who published the remarks in the book, “Light of the World: The Pope, the Church and the Signs of the Times.”

The pope did tell him, though, “one can resign at a peaceful moment or when one simply cannot go on. But one must not run away from danger and say that someone else should do it.”

In another section of the book, the pope told Seewald: “If a pope clearly realizes that he is no longer physically, psychologically and spiritually capable of handling the duties of his office, then he has a right and, under some circumstances, also an obligation to resign.”

— Robert Mackey

1:43 P.M. |Obama and Other World Leaders Praise the Pope

The White House released the following statement on Monday in response to the pope’s resignation:

On behalf of Americans everywhere, Michelle and I wish to extend our appreciation and prayers to His Holiness Pope Benedict XVI. Michelle and I warmly remember our meeting with the Holy Father in 2009, and I have appreciated our work together over these last four years. The Church plays a critical role in the United States and the world, and I wish the best to those who will soon gather to choose His Holiness Pope Benedict XVI’s successor.

President Obama joined many world leaders in paying tribute to the pope on Monday. Angela Merkel, the German chancellor, called the pope, “deeply educated, with a sense for history’s great correlations and a lively interest in the processes of European unification.” She added: “”In an era in which people are living ever longer, many people can understand how the pope is having to deal with the burdens of aging.”

A less somber note was struck by Vice President Joseph R. Biden Jr., a catholic, who joked at a news conference that he would not be running for the papacy.

Reporter yells about the pope retiring. ”Oh,” says Biden. ” No, I’m not running.” #bidenguns
— Tara Murtha (@taramurtha) 11 Feb 13

Ireland’s prime minister, Enda Kenny, who was caught on video checking his phone during a papal address last year, said: “On behalf of the Government and people of Ireland, I would like to extend best wishes to His Holiness Pope Benedict XVI following his declaration today that he intends to step down from his office. This is clearly a decision which the Holy Father has taken following careful consideration and deep prayer and reflection. It reflects his profound sense of duty to the Church, and also his deep appreciation of the unique pressures of spiritual leadership in the modern world.”

Two years ago, Mr. Kenny also attacked the Vatican after a report found that officials there had discouraged efforts by bishops to report cases of sex abuse to the police.” In a speech to the Irish Parliament after the release of the Cloyne Report in 2011, which detailed abuse and cover-ups by church officials, Mr. Kenny said:

for the first time in Ireland, a report into child sexual abuse exposes an attempt by the Holy See to frustrate an inquiry in a sovereign, democratic republic … as little as three years ago, not three decades ago. And in doing so, the Cloyne Report excavates the dysfunction, disconnection, elitism — the narcissism — that dominate the culture of the Vatican to this day.

— Robert Mackey

12:55 P.M. |The Pope’s Decision as ‘the Eruption of Modernity’

Reflecting on Monday’s news, Ezio Mauro, the executive editor of La Repubblica, suggested in a video interview published on the Italian newspaper’s Web site, that the pope’s decision to resign marked “the eruption of modernity” into the papacy.

Mr. Mauro also discussed the possible difficulties the resignation, unprecedented in modern times, could have for the next pope, who will have to deal with not just the memory of his predecessor, but the also the fact of the living man. He added that, although a Vatican spokesman insisted that the pope “was absolutely not depressed,” the scenario unfolding in real life reminded him somewhat of the plot of the Italian director Nanni Moretti’s 2012 comedy “Habemus Papam,” about a reluctant new pope who tries psychoanalysis before ducking out of the Vatican to wander the streets of Rome.

The trailer for the 2012 Italian comedy “Habemus Papam,” about a reluctant pope.

— Robert Mackey

11:59 A.M. |Cardinal Dolan Says He Admires Pope for Decision

Associated Press video of Cardinal Timothy Dolan, archbishop of New York, speaking to reporters on Monday about the pope’s resignation.

Speaking after the pope announced his resignation plans on Monday, Cardinal Timothy Dolan, archbishop of New York, told reporters, “I just always admired him as a scholar, as a priest, as a holy man — and now my admiration for him is even higher because of his humility.” The American cardinal also said in a statement:

The Holy Father brought the tender heart of a pastor, the incisive mind of a scholar and the confidence of a soul united with His God in all he did. His resignation is but another sign of his great care for the Church. We are sad that he will be resigning but grateful for his eight years of selfless leadership as successor of St. Peter.

Though 78 when he elected pope in 2005, he set out to meet his people – and they were of all faiths – all over the world. He visited the religiously threatened – Jews, Muslims and Christians in the war-torn Middle East, the desperately poor in Africa, and the world’s youth gathered to meet him in Australia, Germany and Spain.

He delighted our beloved United States of America when he visited Washington and New York in 2008. As a favored statesman he greeted notables at the White House. As a spiritual leader he led the Catholic community in prayer at Nationals Park, Yankee Stadium and St. Patrick’s Cathedral. As a pastor feeling pain in a stirring, private meeting at the Vatican nunciature in Washington, he brought a listening heart to victims of sexual abuse by clerics.

— Robert Mackey

11:45 A.M. |Speculation Online About Who Comes Next

A video report from the news agency Rome Reports on what happens after the pope’s resignation.

Within hours of the announcement that the pope had resigned, Twitter was filled with speculation as to who would come next, with some hoping it would be an opportunity for a younger, more reform-minded pope, or one drawn from the new Catholic strongholds in the developing world, where more than half the world’s Catholics now reside.

An interesting profile of Cardinal Peter Turkson of Ghana, the most likely African papal candidate. http://t.co/0LLkUh2T #pope
— Lydia Polgreen (@lpolgreen) 11 Feb 13

Name to keep in mind in talk of papal succession: #Brazil’s Cardinal João Braz de Aviz http://t.co/XgNUwGkq & http://t.co/rk25wEz0
— Simon Romero (@viaSimonRomero) 11 Feb 13

I wish the Pope well. Probably next choice won’t be 78 y.o. #conclave
— qestout (@qestout) 11 Feb 13

I believe Cardinal Arinze will be the next Pope. See my booklet of eschatology: The Future and the Popes http://t.co/pdj2nBNa #conclave
— Ronald L. Conte Jr. (@RonConte) 11 Feb 13

Hoping for a Pope from outside Europe or North America . . . #conclave #churchhistorygeek
— Tim Dalton (@timdalton74) 11 Feb 13

Hmm… Gonna be interesting to see what the #Conclave decides. Hopefully a #Pope who is somewhat #liberal. #Popeguy
— Jeanette Widén (@JeanetteWiden) 11 Feb 13

Church insiders speculate that Dolan will not be next #pope because he is from a “superpower”.
— Greg O’Brien (@RealGOBstoppah) 11 Feb 13

As our colleagues Elisabetta Povoledo and Alan Cowell report:

Vatican lore has it that cardinals seen as front-runners in advance of the vote rarely triumph, and Vatican-watchers say there is no clear favorite among several potential contenders: Cardinal Angelo Scola, the archbishop of Milan; Cardinal Christoph Schoenborn, the archbishop of Vienna; and Cardinal Marc Ouellet, the Canadian head of the Vatican’s office for bishops.

As the Vatican explains on its Web site, popes are elected by a conclave of cardinals.

#Vatican spokesman Lombardi says the #conclave will be held in March before Easter #pope #benedict #papalresignation
— Novus Ordo Watch (@NovusOrdoWatch) 11 Feb 13

There are currently 118 Cardinal-electors that can participate in next #Conclave. A two thirds majority is required to elect the new #Pope
— Óscar SánchezBenítez (@osanchezbenitez) 11 Feb 13

The BBC describes the process:

During this period all the cardinals – retirees included – will begin to discuss in strict secrecy the merits of likely candidates. The cardinals do not have to choose one of their own number – theoretically any baptised male Catholic can be elected pope – but tradition says that they will almost certainly give the job to a cardinal….

The only clue about what is going on inside the Sistine Chapel is the smoke that emerges twice a day from burning the ballot papers. Black signals failure. The traditional white smoke means a new pope has been chosen…

After the election of the new pope has been signaled by white smoke rising from the Sistine Chapel chimney, there will be a short delay before his identity is finally revealed to the world.

Among those who called for the church to embrace change and diversity with its selection was the New York Times Op-Ed columnist Nicholas Kristof, who drew a distinction in Catholic service between the papal activities in the Vatican and those who work in some of the poorest places on earth.

Some of the people I most admire are nuns I’ve met doing heroic work in dangerous places. I nominate them for Pope.
— Nicholas Kristof (@NickKristof) 11 Feb 13

As Mr. Kristof observed from southern Sudan in 2010:

As I’ve noted before, there seem to be two Catholic Churches, the old boys’ club of the Vatican and the grass-roots network of humble priests, nuns and laity in places like Sudan. The Vatican certainly supports many charitable efforts, and some bishops and cardinals are exemplary, but overwhelmingly it’s at the grass roots that I find the great soul of the Catholic Church.

— Christine Hauser

11:26 A.M. |Reaction From Germany, Ireland and the U.S.

Television news crews around the world have been sampling street reaction on the pope’s decision to step down.

In Germany, the pope’s native country, there was surprise at the announcement which caught even the German government off-guard, Deutsche Well reports.

The German broadcaster Deutsche Welle sampled reaction in Germany to Pope Benedict XVI’s resignation.

In Ireland, a traditionally Catholic country where the church has been rocked by sexual abuse scandals, The Irish Times found less surprise, and some words of welcome for the idea of a younger pope.

One Catholic in Washington told The Associated Press that his first reaction was to pray and ask for support even from members of other faiths.

Associated Press video on the reaction of American Catholics to the pope’s resignation.

— Robert Mackey

10:20 A.M. |Betting Begins on Next Pope

While many people remain in shock over the pope’s surprise resignation on Monday, bets are already being placed on who will succeed him in one of the world’s most Catholic countries, Ireland.

Next #pope? Bookmakers favouring an African. I’m sceptical. Marc Ouellet of #Canada more likely. And Scola certainly in the running. #news
— John Hooper (@john_hooper) 11 Feb 13

As the Guardian correspondent John Hooper notes, the Irish bookmaker Paddy Power quickly issued odds on the cardinals considered most likely to succeed Benedict — with Cardinal Marc Ouellet, the Canadian head of the Vatican’s office for bishops, Cardinal Francis Arinze, a Nigerian who was converted from animism by Irish missionaries, Cardinal Peter Appiah Turkson of Ghana and Cardinal Angelo Scola, archbishop of Milan, among the early favorites.

Next Pope betting: 5/2 Cardinal Ouellet, 3/1 Cardinal Arinze, 4/1 Cardinal Turkson Web: http://t.co/X3IhCpxO Mobile: http://t.co/WrItgPIK
— Paddy Power (@paddypower) 11 Feb 13

The longest odds offered by the bookie are 1,000 to 1 on the Irish singer Bono, who is not Catholic, and the Irish television star Father Dougal Maguire, who is not real.

In 2005, Cardinal Ouellet, who was then the archbishop of Quebec and primate of Canada’s Catholic Church, warned that legalizing gay marriage “threatens to unleash nothing less than cultural upheaval whose negative consequences are still impossible to predict.”

During the 2004 presidential campaign in the United States, Cardinal Arinze was asked about Senator John Kerry’s support for abortion rights, and replied that a Roman Catholic politician who supports abortion “is not fit” to receive communion.

As my colleague Ian Fisher reported in 2005, Cardinal Scola — who was considered a top Italian candidate to become pope during the previous election — started an Arabic-language magazine, Oasis, that was devoted to improving contacts and dialogue between Christians and Muslims.

Last year, Reuters reported, Cardinal Turkson “caused an uproar at the Vatican by screening a spurious YouTube video that makes alarmist predictions about the growth of Islam in Europe,” to an an international gathering of bishops. The viral YouTube video, “Muslim Demographics,” relies on quotes from Col. Muammar el-Qaddafi and wildly inaccurate population projections from anti-Islam authors to make alarmist claims about the future growth of the Muslim population of Europe and the United States.

— Robert Mackey

9:42 A.M. |Not the First Pope Benedict to Resign

Although, as close observers of social media quickly noted, the pope’s new Pontifex Twitter feed has been mute on his resignation so far, the Vatican press office has been busy online, issuing a string of updates on the Vatican news feed with links to a timeline of Benedict XVI’s papacy, a report on Facebook reaction to the announcement — “Hacked?” — interviews with a papal historian and an expert on canon law on the Vatican Radio’s site.

Virtually unprecedented: papal resignation throughout history
§RV http://t.co/xXccYs7g
— Vatican – news (@news_va_en) 11 Feb 13

In one of those interviews, Donald Prudlo, an associate professor of history who studies “hagiography and saint’s lives, medieval miracle stories, Church History, and the development of canonization” at Jacksonville State University in Alabama, explained that the last pope to resign was Pope Gregory XII, who stepped down almost 600 years ago, “so that the council of Constance could assume his power and appoint a new pope, and in so doing bring an end Great Western Schism.”

Mr. Prudlo added that the pope’s resignation does not have to be accepted by anyone:

At the end of the 13th century, a very holy hermit named Peter was elected as Pope Celestine V in order to break a deadlock in the conclave that had lasted nearly three years. He was elected because of his personal holiness, sort of a unity candidate. And once he got there, being a hermit, not used to the ways of the Roman Curia, he found himself somewhat unsuited to the task, that it wasn’t just holiness but also some shrewdness and prudence that was also required. So within six months he knew that he was really unequal to the task, and so he gathered the cardinals together in a consistory, just as was recently done, a couple hours ago, and he announced to the cardinals his intention to resign. Because of the Pope’s position as the supreme authority in the Church, Celestine declared that the pope could freely resign, that it was permissible, and that, because, as supreme authority, it did not have to be accepted by anyone.

The professor also noted that one of the few previous popes to step down, also named Benedict, apparently had second thoughts about his decision:

Celestine V and his advisers were aware that this was an unusual process. And so what they did is they went back through history, they looked at the Liber Pontificalis, and they could go all the way back to Pope St. Pontian, in 235, one of the first bishops of Rome, who was arrested and sent to the salt mines, and in order for a successor to be able to be elected in Rome, he resigned his office. And so as early as 235 we have evidence of the possibility of Popes resigning for the good of the church. Several others, they tried to force them to resign. The Byzantines attempted to force Pope Silverius to resign, but he refused to. But that also demonstrates the possibility of resignation. And then, at a rather low point in the Church’s history, Pope Benedict IX, in the 1040s, resigned and attempted to re-acquire the papacy several times. But according to good reports, he too died in penance at the monastery of Grottaferrata outside of Rome.

— Robert Mackey

9:02 A.M. |Video of Vatican News Conference

Video of a Vatican news conference on the pope’s resignation, posted online by The Telegraph.

As our Rome bureau chief Rachel Donadio reports, Rev. Federico Lombardi, the Vatican spokesman, told reporters at a news conference on Monday, “The pope took us by surprise.” Among other questions, reporters asked Father Lombardi what the pope will be called after is resignation and what he will wear.

Vaticanisti asking how pope will dress & how he will be called after resignation! #BenedettoXVI
— Rachel Donadio — NYT (@RachelDonadio) 11 Feb 13

The spokesman said he had no answers to those questions.

Father Lombardi also explained that the pope would continue to carry out his duties until Feb. 28 and a successor could be elected by Easter, at the end of March.

Video from the news conference was posted online by The Telegraph.

— Robert Mackey

8:51 A.M. |Text and Video of Pope’s Resignation Announcement

Video of Pope Benedict XVI announcing his resignation in a Latin statement on Monday at the Vatican.

As my colleague Rachel Donadio reports from Rome, Pope Benedict XVI announced on Monday that he would resign in a statement in Latin that he read to a meeting of cardinals who had gathered at the Vatican on other church business.

the @ansa journo who broke news on #pope resignation heard #benedictxvi read news to cardinals in LATIN & understood what he said. brava!
— Rachel Donadio — NYT (@RachelDonadio) 11 Feb 13

Video of the pope reading the announcement in Latin was posted on YouTube by Rome Reports, a news agency that covers the Vatican. This English translation of the complete statement was posted on the official Vatican Radio Web site:

Dear Brothers,
I have convoked you to this Consistory, not only for the three canonizations, but also to communicate to you a decision of great importance for the life of the Church. After having repeatedly examined my conscience before God, I have come to the certainty that my strengths, due to an advanced age, are no longer suited to an adequate exercise of the Petrine ministry. I am well aware that this ministry, due to its essential spiritual nature, must be carried out not only with words and deeds, but no less with prayer and suffering. However, in today’s world, subject to so many rapid changes and shaken by questions of deep relevance for the life of faith, in order to govern the bark of Saint Peter and proclaim the Gospel, both strength of mind and body are necessary, strength which in the last few months, has deteriorated in me to the extent that I have had to recognize my incapacity to adequately fulfill the ministry entrusted to me. For this reason, and well aware of the seriousness of this act, with full freedom I declare that I renounce the ministry of Bishop of Rome, Successor of Saint Peter, entrusted to me by the Cardinals on 19 April 2005, in such a way, that as from 28 February 2013, at 20:00 hours, the See of Rome, the See of Saint Peter, will be vacant and a Conclave to elect the new Supreme Pontiff will have to be convoked by those whose competence it is.
Dear Brothers, I thank you most sincerely for all the love and work with which you have supported me in my ministry and I ask pardon for all my defects. And now, let us entrust the Holy Church to the care of Our Supreme Pastor, Our Lord Jesus Christ, and implore his holy Mother Mary, so that she may assist the Cardinal Fathers with her maternal solicitude, in electing a new Supreme Pontiff. With regard to myself, I wish to also devotedly serve the Holy Church of God in the future through a life dedicated to prayer.

— Robert Mackey

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Body slam for wrestling: Sport cut from Olympics

LAUSANNE, Switzerland (AP) — For wrestling, this may have been the ultimate body slam: getting tossed out of the Olympic rings.

The vote Tuesday by the IOC's executive board stunned the world's wrestlers, who see their sport as popular in many countries and steeped in history as old as the Olympics themselves.

While wrestling will be included at the 2016 Olympics in Rio de Janeiro, it was cut from the games in 2020, which have yet to be awarded to a host city.

2004 Olympic Greco-Roman champion Khasan Baroev of Russia called the decision "mind-boggling."

"I just can't believe it. And what sport will then be added to the Olympic program? What sport is worthy of replacing ours?" Baroev told the ITAR-Tass news agency. "Wrestling is popular in many countries — just see how the medals were distributed at the last Olympics."

American Rulan Gardner, who upset three-time Russian Olympic champion Alexander Karelin at the Sydney Games in an epic gold-medal bout known as the "Miracle on the Mat," was saddened by the decision to drop what he called "a beloved sport."

"It's the IOC trying to change the Olympics to make it more mainstream and more viewer-friendly instead of sticking to what they founded the Olympics on," Gardner told The Associated Press in a telephone interview from Logan, Utah.

The executive board of the International Olympic Committee reviewed the 26 sports on its summer program in order to remove one of them so it could add one later this year. It decided to cut wrestling and keep modern pentathlon — a sport that combines fencing, horse riding, swimming, running and shooting — and was considered to be the most likely to be dropped.

The board voted after reviewing a report by the IOC program commission report that analyzed 39 criteria, including TV ratings, ticket sales, anti-doping policy and global participation and popularity. With no official rankings or recommendations contained in the report, the final decision by the 15-member board was also subject to political, emotional and sentimental factors.

"This is a process of renewing and renovating the program for the Olympics," IOC spokesman Mark Adams said. "In the view of the executive board, this was the best program for the Olympic Games in 2020. It's not a case of what's wrong with wrestling; it is what's right with the 25 core sports."

According to IOC documents obtained by the AP, wrestling ranked "low" in several of the technical criteria, including popularity with the public at the London Games — just below 5 on a scale of 10. Wrestling sold 113,851 tickets in London out of 116,854 available.

Wrestling also ranked "low" in global TV audience with a maximum of 58.5 million viewers and an average of 23 million, the documents show. Internet hits and press coverage were also ranked as low.

The IOC also noted that FILA — the international wrestling federation — has no athletes on its decision-making bodies, no women's commission, no ethics rules for technical officials and no medical official on its executive board.

Modern pentathlon also ranked low in general popularity in London, with 5.2 out of 10. The sport also ranked low in all TV categories, with maximum viewership of 33.5 million and an average of 12.5 million.

FILA has 177 member nations, compared to 108 for modern pentathlon.

Modern pentathlon, which has been on the Olympic program since the 1912 Stockholm Games, was created by French baron Pierre de Coubertin, the founder of the modern Olympic movement.

It also benefited from the work of Juan Antonio Samaranch Jr., the son of the former IOC president who is a UIPM vice president and member of the IOC board.

"We were considered weak in some of the scores in the program commission report but strong in others," Samaranch told the AP. "We played our cards to the best of our ability and stressed the positives."

Klaus Schormann, president of governing body UIPM, lobbied hard to protect his sport's Olympic status and it paid off in the end.

"We have promised things and we have delivered," he said after Tuesday's decision. "That gives me a great feeling. It also gives me new energy to develop our sport further and never give up."

The IOC executive board will meet in May in St. Petersburg, Russia, to decide which sport or sports to propose for 2020 inclusion. The final vote will be made at the IOC session, or general assembly, in September in Buenos Aires, Argentina.

Wrestling will now join seven other sports in applying for 2020, but it is extremely unlikely that it would be voted back in so soon after being removed by the executive board.

The other sports vying for a single opening in 2020 are a combined bid from baseball and softball, karate, squash, roller sports, sport climbing, wakeboarding and wushu, a martial art.

"Today's decision is not final," Adams said. "The session is sovereign and the session will make the final decision."

Wrestling featured 344 athletes competing in 11 medal events in freestyle and seven in Greco-Roman at last year's London Olympics, with Russia dominating the podium but Iran and Azerbaijan making strong showings. Women's wrestling was added to the Olympics at the 2004 Athens Games.

Tuesday's decision came via secret ballot over four rounds, with 14 members voting each time on which sport should not be included in the core group. IOC President Jacques Rogge did not vote.

Three sports were left in the final round: wrestling, field hockey and modern pentathlon. Eight members voted against wrestling and three each against the other two sports. Taekwondo and canoe kayaking survived the previous rounds.

"I was shocked," said IOC board member Rene Fasel of Switzerland.

"It was an extremely difficult decision to take," added IOC Vice President Thomas Bach of Germany. "The motivation of every member is never based on a single reason. There are always several reasons. It was a secret vote. There will always be criticism, but I think the great majority will understand that we took a decision based on facts and for the modernization of the Olympic Games."

Wrestling was featured in the first modern Olympics in Athens in 1896. Along with Russia's Karelin, it has produced such American stars as Gardner, Bruce Baumgartner, Jeff Blatnick and Jordan Burroughs.

U.S. Olympic Committee CEO Scott Blackmun also expressed surprise at the IOC decision, citing "the history and tradition of wrestling, and its popularity and universality."

"It is important to remember that today's action is a recommendation, and we hope that there will be a meaningful opportunity to discuss the important role that wrestling plays in the sports landscape both in the United States and around the world," Blackmun said in a statement. "In the meantime, we will fully support USA Wrestling and its athletes."

FILA said in a statement that it was "greatly astonished" by the decision, adding that the federation "will take all necessary measures to convince the IOC executive board and IOC members of the aberration of such decision against one of the founding sports of the ancient and modern Olympic Games."

It said it has always complied with IOC regulations and is represented in 180 countries, with wrestling the national sport in some of them.

The federation, which is headed by Raphael Martinetti and based in Corsier-sur-Vevey, Switzerland, said it would meet next week in Thailand to discuss the matter.

Gardner cited wrestling's worldwide popularity and urged a campaign to keep it in the Olympics.

"It just seems like wrestling — if we don't fight, we're going to die," he said. "At this point, it's time for everybody to man up and support the program."

The decision hit hard in Russia, which has long been a power in the sport.

Mikhail Mamiashvili, president of the Russian Wrestling Federation, suggested FILA had not done enough to keep the sport in the games.

"We want to hear what was done to prevent this issue from even being discussed at the board," he said on the Rossiya TV channel.

In comments carried by ITAR-Tass, Mamiashvili added: "I can say for sure that the roots of this problem is at the FILA. I believe that Martinetti's task was to work hard, socialize and defend wrestling's place before the IOC."

Alexander Leipold, a 2000 Olympic champion from Germany and former freestyle German team coach, said he was shocked.

"We are a technical, tactical martial sport where the aim is not to harm the opponent," he said. "Competing at the Olympics is the greatest for an athlete."

Wrestling's long history in the Olympics has featured some legendary names and moments:

— Karelin won the super-heavyweight gold in Greco-Roman over three straight Olympics — 1988, 1992 and 1996 — until his streak was ended by Gardner, who beat him for the gold in 2000.

— Baumgartner won four Olympic medals, including golds in 1984 and 1992.

— Blatnick overcame cancer to win gold in Greco-Roman at the 1984 Los Angeles Games, bursting into tears after the match. Blatnick died last year at age 55.

— Burroughs emerged as the star of the sport in London, where he won the 74-kilogram gold.

The last sports removed from the Olympics were baseball and softball, voted out by the IOC in 2005 and off the program since the 2008 Beijing Games. Golf and rugby will be joining the program at the 2016 Games in Rio.

Among those in Lausanne were the leaders of the recently created World Baseball Softball Confederation. The two sports agreed last year to merge in a joint bid to return to the games.

Don Porter, the American who heads international softball, and Riccardo Fraccari, the Italian who leads baseball, are working out the final details of their unified body ahead of their presentation to the IOC in May.

A major hurdle remains the lack of a commitment from Major League Baseball to release top players for the Olympics.

Porter and Fraccari said they hope to have another meeting with MLB officials in April in Tokyo.

"The next thing is to sit down with them and see how they can help us," Porter said. "It all depends on the timing, the timing of the season. It's not an easy decision to allow players a week off."

___

Associated Press writers Lynn Berry in Moscow and Luke Meredith in Des Moines, Iowa, contributed to this story.

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Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

---

Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 12, 2013

An earlier version of this article misstated the location of the Medical College of Wisconsin. It is in Milwaukee, not Madison.

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Media Decoder Blog: Netflix Teams With DreamWorks Animation to Create Cartoon Series

LOS ANGELES — Continuing a campaign to deepen its appeal to children, Netflix on Tuesday announced a partnership with DreamWorks Animation to create an original cartoon series.

The show, expected to make its debut on the streaming service in December, will be based on DreamWorks Animation’s coming movie “Turbo,” about a snail who gains the power of superspeed. The Netflix spinoff will be called “Turbo: F.A.S.T.,” which stands for Fast Action Stunt Team.

Netflix is gambling that “Turbo” will be a hit when it arrives in theaters on July 19. Although DreamWorks Animation has high hopes for that movie, it’s still anyone’s guess how audiences will respond; the company’s last film, “Rise of the Guardians,” was a box-office disappointment.

Ted Sarandos, Netflix’s chief content officer, said in a statement that DreamWorks Animation had “a long track record of creating incredibly successful characters.” DreamWorks Animation’s chief executive, Jeffrey Katzenberg, never shy about making a hard sell, called the partnership “part of the television revolution.”

A rival streaming service, Amazon’s Prime Instant Video, is racing to prepare its own original series, and has five children’s shows in development.

Netflix, which recently introduced the original series “House of Cards” to strong reviews from critics, has been working over the last several years to enhance its offerings for children. In 2011, it acquired the streaming rights to DreamWorks Animation’s movies and television specials. New films from Disney, Pixar and Marvel will move from Starz to Netflix in late 2016, following a deal the streaming company made with the Walt Disney Company in December.

Netflix said its members streamed more than two billion hours of children’s content in 2012, taking care to note that it is “always commercial free.” Netflix is also trying to enhance its appeal with multiple audience niches. A new horror series called “Hemlock Grove” is on the way, for instance. “Orange Is the New Black,” an original comedic drama from the “Weeds” creator Jenji Kohan, is aimed at women.

Children’s programming is particularly important to the company’s growth plans. Children are avid streaming consumers, particularly overseas, and Netflix can pitch itself to parents as a commercial-free alternative to television. Cartoons are also less likely to appear on the pirated-content sites that compete with Netflix for viewers.

For DreamWorks Animation, the agreement is part of an effort to diversify into television both as a way to grow and to avoid the sharp ups and downs of the movie business. The company’s shares rose 2.91 percent on Tuesday, to $16.63.

The company has two shows on Nickelodeon that are spinoffs of its “Madagascar” and “Kung Fu Panda” films; a third series built around “Monsters vs. Aliens” is in the works. DreamWorks Animation also has a series built around the film “How to Train Your Dragon” on the Cartoon Network, as well as a growing number of holiday-themed television specials.

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